A BILL to amend and reenact §§ 38.2-3418.15 and 38.2-3418.15:1 of the Code of Virginia and to amend the Code of Virginia by adding a section numbered 32.1-325.6, relating to health insurance; State Plan for Medical Assistance; coverage for prosthetic and custom orthotic devices and components; reports.
HB216 would expand and standardize coverage for medically necessary prosthetic devices and custom orthotic devices, along with repairs, fittings, replacements, and components, across Virginia’s private health insurance market and Medicaid. The bill amends existing insurance mandates for individual and group policies and health maintenance organizations, and it creates a new Medicaid coverage section requiring the Department of Medical Assistance Services to provide comparable benefits, subject to federal approval and federal financial participation. The bill also defines key terms such as prosthetic device, orthotic device, limb, component, and medically necessary prosthetic device.
Under the bill, coverage would have to include the most appropriate devices needed for daily living, work-related activities, physical activity, and bathing/showering when medically necessary. It also bars denials based on disability status, requires access to at least two in-network providers, allows out-of-network referral and reimbursement when needed, limits coinsurance for in-network services, and requires written explanations for medical-necessity denials. The bill further requires carriers and Medicaid administrators to report implementation data for 2027 and 2028, with aggregated reports due to the Governor and General Assembly in 2029.
HB216 would amend §§ 38.2-3418.15 and 38.2-3418.15:1 of the Code of Virginia and add § 32.1-325.6, thereby expanding state insurance mandates and creating a parallel Medicaid coverage requirement for prosthetic and custom orthotic devices. It would affect insurers, health maintenance organizations, Medicaid managed care plans, the Department of Medical Assistance Services, and enrollees who need prosthetic or orthotic care. The Medicaid portion is contingent on federal approval and federal financial participation, and the bill includes a fallback expiration date for that section if federal approval is not obtained.
The bill appears to be generally favorable in concept, as reflected by its introduction with multiple patrons and no recorded opposition, votes, or committee testimony in the provided materials. Its structure suggests a consumer- and patient-protection approach aimed at improving access to medically necessary mobility and rehabilitation devices. However, because the bill was left in the Labor and Commerce committee and no transcript is available, there is no documented floor or committee sentiment beyond its introduction and referral.
The main points of potential contention are likely cost, utilization management, and federal-state implementation issues. Insurers and Medicaid administrators may be concerned about expanded benefit obligations, network adequacy requirements, out-of-network reimbursement, and limits on denials and cost-sharing. The bill also requires Medicaid implementation to depend on federal approval and matching funds, which could be a practical and fiscal sticking point. Another possible area of debate is the breadth of coverage for multiple devices and for devices used in physical activities, which may raise questions about medical necessity and premium or program cost impacts.